A Master Athlete with CAD During the COVID-19 Pandemic
A 54-year-old healthy active female runner with no significant past medical history presents with dyspnea on exertion. She is training for a marathon, of which she has run many, and noted that early in her runs she would become significantly short of breath, out of proportion to workout intensity. She felt it might be due to exercise-induced asthma, as it resolved with slowing her pace and she could continue her training run. Despite her history of asthma, her symptoms raised concern for "warmup angina". An exercise single photon emission computed tomography (SPECT) stress test was ordered for further evaluation. She completed 15 metabolic equivalents of task (METs) without developing test limiting symptoms or significant arrhythmia. Although imaging demonstrated normal perfusion, her electrocardiogram (ECG) was notable for 2mm ST depressions that developed in stage 4 persisting into recovery with frequent ventricular ectopy that developed in recovery. She was subsequently sent for a coronary computerized tomography (CT) angiography which showed a calcium score of 193 (98th percentile) and a severe, 70-99% proximal mixed plaque stenosis of the left-anterior-descending (LAD) coronary artery without evidence of other obstructive coronary artery disease. (Figures 1-2).
She was quickly brought to the catheterization lab where an estimated 80% LAD stenosis was confirmed. Optical coherence tomography (OCT) was performed demonstrating a moderate diffuse, lipid rich plaque with no significant calcification nor evidence of dissection in the vessel. The lesion was successfully stented (Figure 3) and proper expansion was confirmed again by OCT. Her low-density lipoprotein (LDL) at baseline was 77mg/dL and high-density lipoprotein (HDL) was 139mg/dL. She was started on dual antiplatelet therapy and a high intensity statin. A beta blocker was not started due to concerns for its effect on exercise tolerance.
The patient has recovered well from her stenting procedure and at her follow-up appointment is asking for guidance about how to safely return to running. Cardiac rehabilitation is closed due to the COVID-19 pandemic as are all the nearby gyms.
What guidance would you give this patient on how to safely return to activity during the COVID-19 pandemic where traditional cardiac rehabilitation is not readily available?